Nutrition Support for Patients with Morbid Obesity in Critical Care Major Case Study By: Amanda Hunter, Dietetic Intern

Case Study Patient: JK Admitting Dx: Septic shock, acute renal failure Hx: COPD, CHF, Pulmonary hypertension, Chronic respiratory failure, DVT s/p IVC filter placement, CKD, HTN, GI bleeding on Coumadin, Diverticular disease, OSA, morbid obesity, breast cancer (s/p mastectomy), endometrial cancer (s/p hysterectom Height: 157cm (5’2”) Weight: 184kg (405lbs) BMI: 75 Age: 68yo Sex: Female Social History: Marital status: Married Residence: Nursing Home, bed bound Ethnicity: African American Religion: Unknown Insurance: Medicare

Case Study Patient: JK Objective: Why chosen? To expand my knowledge of nutrition support in the critical care setting, and learn how morbid obesity affects critical care parameters Focus of study: Nutrition support for obese patient in critical care

Pathophysiology: JK was admitted to the ICU with the diagnosis of septic shock and acute renal failure. JK presented with additional comorbid conditions including: morbid obesity, chronic respiratory failure, HCAP, CHF, CKD.   JK’s critical medical status required ventilator support, IV fluids, hemodialysis, and nutrition support.  

Past Medical History of JK Hospitalization at Central DuPage for atrial fibrillation and respiratory distress. There, the patient was not tolerating CPAP and was started on Cardizem infusion.  The patient developed a GI bleed and was taken off Coumadin. The patient was ventilated and developed healthcare-acquired pneumonia / ventilator associated pneumonia.  The patient was diagnosed with chronic respiratory failure with difficulty weaning from the ventilator.  A tracheostomy was placed and the patient was transferred to RML for ventilary weaning. At RML, JK had diuretic therapy for continued issues with fluid overload.  JK was given Bumex, a potent diuretic, and despite the interventions, had worsening renal failure associated with oliguria. JK also developed hematuria and was transferred to Adventist Hinsdale for acute renal failure with septic shock.

Present Medical Status: Septic Shock Septic shock is a widespread infection that leads to dangerously low blood pressure. Commonly caused by bacteria, and JK tested positive for MRSA JK’s risk factors for septic shock: an indwelling catheter, long-term use of antibiotics, recent infection, and recent steroid JK’s symptoms of septic shock: oliguria, low blood pressure, SOB

Treatment for Septic Shock Medical emergency – immediate treatment  Patients often ICU, treatments include:  mechanical ventilation, dialysis, drugs to treat low blood pressure, infection, or blood clotting, IV fluids, oxygen, sedatives, and surgery. Prognosis: poor with a high death rate.  Depends on the patient’s age, overall health, the cause of infection, the number of failed organs, and how quickly medical therapy is initiated. (1)

IPOC Treatment for JK: Treatment for JK included multidisciplinary team: Intensive care MDs, renal, cardiac, pulmonary, infectious disease, nutrition, pharmacist, palliative care Treatment Timeline

Medical Nutrition Therapy Nutrition history: Enteral nutrition via G-tube pta Current Prescribed diet: TPN s/p EN intolerance Pt’s response to diet: EN failed to achieve goal rate d/t intolerance and altered GI function. TPN initiated, but d/c’d before goal rate when pt’s status changed to comfort care and was extubated.

Medical Nutrition Therapy Nutrition related problems: Swallowing difficulty related to chronic respiratory failure and COPD, as evidenced by NPO, ventilated, PEG in place for nutrition support Altered GI function related to SBO, as evidenced by NPO, abdominal distention, TPN Nutrition Goals: Initiate EN: Nepro @ 30mls/hr goal rate will provide 1296 kcal, 58g pro, which basically meets pt’s est needs. Achieve/maintain goal rate via TPN: 70g AA, 250g dextrose, 40g lipids (1530 kcal, 70g pro, 250g CHO) which basically meets pt’s est reassessed needs.

Medical Nutrition Therapy: Nutrition Intervention: JK was evaluated for enteral nutrition support via G-tube. JK’s energy and protein requirements were estimated to be 1144-1300 kcal / day and 57-73g protein / day. These calories were calculated using 22-25 kcal / kg IBW based on the JK’s ICU status and BMI > 30. The protein requirements were calculated using 1.1-1.4 g / kg IBW based on JK’s renal status of ESRD on dialysis.

Medical Nutrition Therapy: Nutrition Monitoring and Evaluation: The MNT goals were monitored and re-evaluated daily. Tube feedings were first held due to a clogged G-tube and then due to vomiting and abdominal distention. Tube feedings d/c when SBO was suspected. 29 # weight loss in 7 days was noted. JK was reassessed for TPN and caloric needs were estimated to be 1100 - 1250 - 2565 kcal based on 22-25 kcal / kg IBW and 14 kcal / kg actual wt. TPN was initiated 48 hours after TF was held, given 2 days. Feedings were increased gradually to reduce the risk of refeeding syndrome, and labs were followed to assess tolerance

Prognosis, Summary and Conclusion Present nutritional status: TPN was discontinued after two days when comfort care and extubation were decided upon. Prognosis: JK deceased from septic shock after extubation. Summary and Conclusion: I learned a significant amount about nutrition support in doing this case study. I reviewed the MNT guidelines for both enteral and parenteral nutrition since both were utilized in this case study. The patient I chose had a very complicated medical history, which was overwhelming, but I am glad that I challenged myself with investigating this case.

References References: "Enteral Nutrition." Nutrition Care Manual. Academy of Nutrition and Dietetics, 1 Jan. 2015. Web. 12 Feb. 2015. “Parenteral Nutrition.” Nutrition Care Manual. Academy of Nutrition and Dietetics, 1 Jan. 2015. Web. 12 Feb. 2015. ASPEN. "ASPEN Clinical Guidelines: Nutrition Support of Hospitalized Adult Patients with Obesity." Journal of Parenteral and Enteral Nutrition 37.6 (2013): 714-44. Sage Journals. Web. 12 Feb. 2015. <http://pen.sagepub.com/content/37/6/714.full.pdf html>. Martino J, Stapleton R, Heyland D, et al. Extreme Obesity and Outcomes in Critically Ill Patients. Chest [serial online]. November 2011;140(5):1198-1206. Available from: Academic Search Complete, Ipswich, MA. Accessed January 28, 2015. Mesejo A, Alvarez C, Sánchez J. Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus SEMICYUC-SENPE: Obese patient. Nutricion Hospitalaria [serial online]. November 2, 2011;:54-58. Available from: Academic Search Complete, Ipswich, MA. Accessed January 27, 2015.  

References 6. Martindale, Robert; et el. "Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient" Critical Care Med. 5th ed. SCCM, 2009. Print. 7. Blot SI, Poelaert J, Kollef M. How to avoid microaspiration? A key element for the prevention of ventilator-associated pneumonia in intubated ICU patients. BMC Infectious Diseases 2014;14(1):119. doi:10.1186/1471-2334-14-119. 8. "Critical Illness: Gastric Vs Small Bowel Feeding." EAL. Academy of Nutrition and Dietetics, 1 Jan. 2011. Web. 12 Feb. 2015. <http://www.andeal.org/topic.cfm?cat=4761&evidence_summary_id=251385&highlight=enteral nutrition ventilated&home=1>. 9. Seres DS, Valcarcel M, Guillaume A. Advantages of enteral nutrition over parenteral nutrition. Therapeutic Advances in Gastroenterology 2013;6(2):157-167. doi:10.1177/1756283X12467564. 10. Brusco, Louis. "Critical Care for Morbidly Obese." Current Concepts. 14th ed. SCCM, 2011. Print. 11. "Septic Shock: MedlinePlus Medical Encyclopedia." U.S National Library of Medicine. U.S. National Library of Medicine, 8 Feb. 2014. Web. 12 Feb. 2015